093_HB2772

 
                                     LRB093 07796 JLS 07985 b

 1        AN ACT concerning insurance.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  5.  The  Illinois  Insurance  Code is amended by
 5    adding Section 368c as follows:

 6        (215 ILCS 5/368c new)
 7        Sec. 368c.  Payment rates.
 8        (a)  Health care professionals or health  care  providers
 9    offered   a   contract  by  an  insurer,  health  maintenance
10    organization,   independent    practice    association,    or
11    physician-hospital organization shall be allowed to ascertain
12    the  payment  amounts  for  each  health  care  service to be
13    provided under the contract prior to signing the contract. If
14    the health care professional or health care provider  is  not
15    paid  on  a service by service basis, the amounts payable and
16    terms of payment under that alternative payment system  shall
17    be stated or ascertainable.
18        (b)  Payments   under  a  contract  with  a  health  care
19    professional or health care provider shall not be based  upon
20    rates  agreed  to  by the professional or provider in another
21    contract.
22        (c)  Payment to a professional or provider  for  services
23    provided  may  not  be  reduced using an amount, discount, or
24    payment   reduction   formula   or   methodology   that   the
25    professional or provider has not  directly  and  specifically
26    agreed  upon  and  is not included in the written contract as
27    applying to the service in question.
28        (d)  A payment statement shall be furnished to  a  health
29    care  professional  or  health  care  provider  for  services
30    provided  under  the contract that identifies the disposition
31    of each claim,  including  services  billed,  the  contracted
 
                            -2-      LRB093 07796 JLS 07985 b
 1    payment  rates,  and  the  actual  payment,  if  any, for the
 2    services billed by CPT or other appropriate code, the  reason
 3    for  any  payment reduction to the claim submitted, including
 4    any withholds and the reason for denial of any claim. Nothing
 5    in this Section requires that a health care  professional  or
 6    health  care  provider be paid on a service by service basis.
 7    Payments may be made based on capitation  and  other  payment
 8    arrangements.  Health  care  professionals  and  health  care
 9    providers  shall be allowed to collect any difference between
10    the amount paid and the amount due under the contract between
11    the company and the health care professional or  health  care
12    provider, except as otherwise provided by law.

13        Section  99.  Effective  date.  This  Act takes effect on
14    December 1, 2003.